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- � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR 0 FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone.: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION .OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -a <br /> (Complete In Triplicate) 1W <br /> and/or install <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> the work herein described. This application is made in compliance with San Joaquir <br /> County Ordinance No. 1862 and the'Rules and Regulations of the San Joaquin Local Health Districtt, <br /> JOB ADDRESS/LOCATION , <br /> CENSUS TRACT <br /> i Owner's Name �C�� j " <br /> Phone <br /> Address �� ��. <br /> City <br /> Contractor's Name , <br /> License # ZO-31, Phone <br /> TYPE•OF WORK (Check):==NEW WELL / / DEEPEN / / RECONDITION 1-7 DESTRUCTION /_7 - �- <br /> PUMP INSTALLATION _/ / PUMP REPAIR / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> OTHER <br /> INTENDED USE TYPE OF WELL <br /> t industrial CONSTRUCTION SPECIFICATIONS <br /> ----- Cable Tool Dia, of Well Excavation <br /> Domestic/private 5 Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> OtherRotary ' Type of Grout <br /> Other _ Other Information <br /> r <br /> r PUMP INSTALLATION. Contractor ' i <br /> " Type of Pump �} <br /> 1 <br /> H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> ' 1 <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION -01'WELL: -We11�-Diameter - <br /> Describe Material and Procedure Approximate Aepth <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS ` <br /> after completion of my work 'on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use., The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED � <br /> TITLE <br /> (DRA�PT& EV:LE <br /> DNRRSE SIDE ` <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PRASE II GROUT INSPECTION PHAS <br /> INSPECTION BY DATE AL INSPECTIO <br /> INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PNSP TRIOR TO GROUTING AND FINAL I <br /> S H 1426 7172 lMM , � <br />